SOE 2023: Cataract surgery in the opaque cornea: Challenging but worthwhile

Corneal opacity is a relatively common situation when dealing with corneal disease in patients who have experienced trauma or the elderly. Image credit: ©DragonImages – stock.adobe.com

When a patient with a cataract and corneal opacity presents, the question arises about whether cataract surgery and corneal graft surgery should be performed simultaneously. The definitive answer depends on the patient status and surgeon skills, according to Jorge L. Alió, MD, PhD, FEBOphth, Professor and Chairman of Ophthalmology, and Founder Vissum Miranza, Alicante, Spain. He shared his pearls for these challenging cases at the European Society of Ophthalmology Conference, Prague.

Corneal opacity is a relatively common situation when dealing with corneal disease in patients who have experienced trauma or in those who are elderly. The potential for achieving improved vision after only cataract removal should be evaluated with care.

“Careful evaluation of these cases is mandatory. In many of these cases, corneal grafting is ultimately not needed, which saves time and inconvenience for patients and medical community,” he commented.

In these cases, the preoperative evaluation is of paramount importance. The corneal opacity may result from corneal dystrophies or corneal scars from previous trauma or infection. They may limit the postoperative visual outcome depending on their location, density, and ability to induce irregular astigmatism.

In the event of a previous trauma with resultant scarring, he advised that surgeons correct regular astigmatism with customized toric intraocular lenses (IOLs). Assessing the risks and potential success of corneal grafting is essential in the decision-making, in that some cases face a high risk of failure.

Cases of cataract surgery only

If the corneal regularity is acceptable or mostly regular, cataract surgery itself alone may be indicated by enhancing intraoperative visualization and the use of toric IOLs. Patients with severely aberrated and opaque corneas may be candidates for a corneal graft procedure and cataract surgery.

Surgical recommendations

Controlling illumination during cataract surgery is a key factor in such cases. He uses a shielded widefield endoilluminator inserted through a limbal paracentesis. Transcorneal oblique illumination provides less illumination than endoillumination.

Dr Alió uses 2% hydroxypropyl methylcelluloseto coat the cornea, red reflex enhancement, Trypan Blue capsular stain, and manipulating the eye to look through clear corneal parts.

He advised testing the eye using microscopy. If the corneal opacity is dense and central with a depth reaching or exceeding the posterior stroma, penetrating keratoplasty or deep anterior lamellar keratoplasty should be considered at the time of cataract surgery.

He described a representative case of a healthy 73-year-old man from Colombia. The ophthalmic history revealed no light perception vision in the right eye because of a previous trauma. The best-corrected distance visual acuity in the left eye was 0.1 (-). The left eye had alimbal stem cell deficiency of autoimmune etiology and a dense cataract; the prognosis for a corneal graft in this eye was extremely poor. The patient refused corneal surgery.

In this case, Dr Alió planned a cataract surgery and implantation of a customized 8 diopter toric IOL in the left eye. The visual outcome was 0.6 decimal visual acuity.

Dr Alió summarized, “Cataract surgery is an opportunity to recover useful vision in many patients with a potentially poor outcome after corneal graft surgery. Surgeons can benefit from endoillumination procedures to improve surgical visualization, capsular staining, and microinstruments to perform these cases successfully. Surgeon wisdom and experience are necessary to reach the optimal outcome. In many of these cases, corneal grafting ultimately is not necessary, saving time and inconvenience for the patient and surgeon.”